Appalachia Today: Part 5 – The Health of Appalachia

Appalachia, and particularly central Appalachia, has the highest rates of diseases in leads the nation in many of the most serious health conditions including cancer, diabetes and obesity. In 2014, Kentucky had the highest death rate from cancer in the country.[i] Cervical, colorectal and lung cancer rates are much higher in Appalachia than nationwide.[ii] Heart disease in Kentucky was 84% higher than the national average, diabetes was 47% higher and lung cancer deaths were 83% higher.[iii]

West Virginia and Kentucky lead the nation in the percentage of smokers. West Virginia is the state with the most smokers in the U.S. (26.7% of adults), with Kentucky a close second (26.2% of adults).[iv] Diabetes is widespread in the region. In 2012, an estimated 1/3 of the population in Appalachia was diabetic. If current trends continue, in a quarter century 50% of the population in the Appalachian region is expected to have diabetes.[v]

In addition, 81% of the counties in Appalachia have high rates of obesity,[vi] with West Virginia in 2015 having the highest rate of adult obesity in the nation, according to Gallup data.[vii]

West Virginia had the highest adult obesity rate in the country in 2015, at 37.0%, according to Gallup, while Kentucky comes in ninth place, with a 31.4% adult obesity rate.[viii] One study on obesity among Appalachian women found several factors contributing to the problem. Two obvious issues were a lack of regular physical activity and a poor diet. Due to the lower incomes in the region, many people choose to eat cheaper, less nutritious foods such as refined grains, red meat and foods high in sugar and saturated fats, instead of healthier options such as lean meat, fish and fresh fruits and vegetables. As a general matter, those living in suburban and urban areas who have higher incomes and are better educated report better health than those living in rural areas, such as Appalachia.[ix]

Many of these severe health problems such as black lung or obesity in Appalachia can be tied to the coal industry and the poverty long associated with the mining of coal in the region.

For example, health problems such as obesity and diabetes can be partly attributed to so-called “food deserts.” When an industry begins to collapse in an area, like coal mining has in Appalachia, businesses, such as grocery stores, shut down, reducing people’s access to fresh produce and unprocessed meats. Poorer people in the area, who often lack access to transportation, are forced to turn to convenience stores or gas stations for their food and end up consuming processed, high-sodium and fatty foods.[x]

A direct link between coal mining and health problems also occurs in the coal mining counties where mountaintop removal mining is practiced. Since 2007, studies by researchers from over a dozen universities have concluded that MTR leads to higher rates of birth defects, cancer and cardiovascular and respiratory diseases. More specifically, researchers have directly tied MTR to four distinct categories of health problems:[xi]

Cancer: In 2011, a study found that cancer rates in Appalachian counties with MTR operations are nearly double the rates in nearby counties where MTR is not practiced. 60,000 cases of cancer in Appalachia have been directly linked to MTR.

Lung cancer and other respiratory diseases: Similarly, the rates of lung cancer and other respiratory diseases are also higher in areas where MTR is practiced than in areas where it is not. In 2014, researchers used dust samples to demonstrate that the dust produced by MTR operations promotes the growth of lung cancer cells among people living nearby.

Heart attacks and cardiovascular disease: A 2011 study found that as coal production in an area increased, so did the rate of heart disease. Researchers estimate that coal mining contributes to an additional 1,072 deaths annually from cardiovascular diseases in Appalachia, with 703 of those deaths occurring in areas where MTR is practiced.

Shortened lives and preventable deaths: In a ten-year period between 1997 and 2007, the two largest coal-producing counties in Kentucky, Perry and Pike County, were among the bottom ten counties nationwide in terms of life expectancy. Likewise, the coal-producing counties of McDowell, Logan and Mingo in West Virginia were among the lowest 1% in the nation in terms of life expectancy. Finally, between 2000 and 2007, a study of 400 Appalachian and non-Appalachian counties found that mortality rates were highest in those counties in which MTR was practiced.

Photo: A technician at the black lung laboratory in the Appalachian Regional Hospital in Beckley West Virginia, monitors a miner whose lung capacity is being tested in the early 1970s

Another major health problem in Appalachia directly linked to coal mining is black lung disease. In recent years, there has been a dramatic rise in the prevalence of the disease, with miners working in small mining operations in Kentucky, Virginia and West Virginia most severely affected.[xii] What is most concerning is the rise in “complicated” black lung, or progressive massive fibrosis (PMF). The rates of PMF rose between 2000 and 2012 to levels not seen since the 1970s, when laws to limit the exposure of miners to coal dust were enacted.[xiii] While the National Institute for Occupational Safety and Health (NIOSH) only reported 99 cases of PMF in the whole country over the last five years, an NPR investigation uncovered a total of 962 cases so far this decade, through data obtained from 11 black lung clinics in Virginia, West Virginia, Pennsylvania and Ohio.[xiv]

The sharp rise in the prevalence of PMF is startling. In 2000, PMF affected only 0.33% of miners who had worked at least 25 years underground. By 2012, the incidence of PMF had risen 900%, affecting 3.23% of miners who worked at least 25 years underground.[xv] PMF is also striking earlier, with many of those afflicted only in their 30s and 40s, having worked less than 20 years underground.[xvi] The disease is debilitating. As one miner who was diagnosed with PMF described it, “You literally suffocate because you can’t get enough air.”[xvii]

As is evident from the discrepancy between NIOSH’s and NPR’s data, the prevalence of PMF has been grossly underreported. One reason for this is that many miners avoid being tested for black lung, a service which is provided by NIOSH. Even though the results of the test are not shared with a miner’s employer, many miners still fear that if their employer were to find out about a black lung diagnosis, they would be fired. As a former miner put it, “As long as you’re working and producing you’re an asset. But now when you get something wrong with you, you become a liability.”[xviii]

Photo: A coal miner using spirometry to test his lung function

Experts have identified several reasons why PMF is on the rise in Appalachia. The thinner coal seams that are left produce silica dust when mined which is especially harmful to lung tissue. Slope mining is also practiced in Appalachia, which involves cutting through solid rock to reach coal seams. As one miner described the process, “I had my respirators on and you’d actually have to remove it to help take a breath every once in a while because the dust packed so much around your filters you couldn’t get no air in.”[xix] Finally, coal companies have also been lax in complying safety and health standards, such as dust levels in the mine. For example, there are many documented cases in which mine officials instructed employees to tamper with the accurate measurement of dust levels in the mine when inspectors came to visit.[xx]

Chapter V Appendix

Part of the problem arises from the lack of regular screenings and preventive care due in part to a shortage of doctors. In 2010 in Kentucky, for example, there were 213.5 physicians for every 100,000 people, whereas the national average was 267.9 physicians per 100,000 people. So, in order to reach the national average, Kentucky would need an additional 2,200 physicians. This shortage is especially problematic for those relying on Medicaid, since many doctors and clinics do not accept Medicaid due to low or late reimbursements. So, patients in rural Appalachia often have to travel far from home to cities like Lexington, KY and Charleston, WV in order to find a doctor who will accept their insurance.[xxi] Looking at the other side of the coin, patients who are not covered by Medicaid or Medicare often cannot afford to seek proper care. Diabetes drugs, for example, can cost $75-100 out-of-pocket, and patients also have to factor in the costs of doctor visits and of gas for driving to clinics far from home.[xxii]